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Inspections
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�� THlS APPLICANT [S ❑ OWNEK �ONTRACTOI:
PROPER'['Y
OWNER/
TEN�:NT
CONTRACTOR
SUI3M1']� A COPY OF
YOURSTATF
LICCNSE. BOND AND
CERTIFICATE OF
INSURANCE
PERMIT TYPE
TYPE OF WORK:
! �vnur
Permit No.:
Received By:
Date Rec�cE:
n��R�:ss� (03 6� �41�(c o� +J � ciT�' l��i.�pf.�sTnr���� zi����Z.
r�HONr.���63 �' � f S"3 ?�,
NAME ��L��
STATE LICF.NSI-; �
8XP DATG
S'I�ATE BOND # EXV DATE
ADDRESS �ai._-g 0 �"'t �,y�, Sl� !�1 � CITY Fl�.� S1'ATE H"� ZIP� S�.3L
PHON[ _ %C�3 Z��' ��Z i� FAX
SINGLC FAMILY
❑ NEW
❑ TWO FAMILY ❑ TOWNHOUS�
�REPLACEMENT
DETAILED DESCRIPTION OF WORK ��S ,� ( j � �rp ��cs_�--c �,-� � � f � �,�.. L� L,e-� �--
FEES ARE BASED ON $10.00 PER FIXTURE, �XCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$35.50.
BATH SINK/LAV FLOORDRAINS S}IOWER WATERPIPING
BATLITUB GAS PIPING (NEF,D CITY L1C) SWIMMINU POOL WATER SOFTNER ($35)
CLOTI�ES WASHER KITCHCN SINK WATER CLOSET BACKFLOW PREV. ($15)
_ DISHWASHER LAUNDRY TRAY �WATER HEATER ($35) FOR IRRIGATION
WA"I'EK METER OTHGR
Number�offixhires�`ca $-t0.{?0 ��x�10.00=$ � �
Number of fixtures (It�, ��l S.OG � �1�S.Q0��— $ ��� � �
�
?�umber of fixtures �r, �3i.00 � $35.00 — $ � � °=��`'
State Surcharge �� $ 5.00 ��
fi�'TI1vIMIJM $40.00) � Tota1=�� �� .�`�`� � �
THIS IS AN APYLICATIOU POIZ A PLRMIT-NO'I' VALID UNTIL PROCESSGD
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the Ciry of Fridley and with the Minnesota Construction Codes; that 1 understand this is
not a pennit but only an applicatio or a permit and work is not to start without a permit on site; that the work will be in accordance
with the approved plan in the�� f al rk which requires review and approval of plans.
SIGNATURE 01 APPLICANT �� '�!-A PRINT NAM� �(n r(LS /2- e�n �, DATE �,� ( - { �_
APPROVALINSPECTORSSIGNATURE DATG � '
PLEASE NOTE: SEPARATE AER . E EOUI �`012 BLILDING. ELECTTtICAL AND MECHANtCAL WnRK
City of Fridley
Building Inspections Department
6431 Unlversiry Avenue NE, Fridley, MI�i »432
76 �-�72-3604
FAX: 763-�02-4977